Thursday, October 09, 2008

Doctors and other health care providers work in extraordinary times and have unrivaled abilities, but increasingly our health care system gets in the way of their sound medical judgment. Increasing uncompensated care loads, administrative rules, and insurers' coverage decisions inappropriately influence the practice of medicine. Washington sends dictates but no help.

We need health care reform now. All Americans should have high-quality, affordable medical care that improves health and reduces the burdens on providers and families. Reform must emphasize prevention, not just treatment of the sick; reduce medical errors and malpractice claims; and make the practice of medicine rewarding again. I believe that by working together we can make these goals a reality.

My health care plan has three central tenets. First, all Americans should have access to the benefits of modern medicine. Once and for all, we must ensure that this great country lives up to its ideals and ensures all Americans access to high-quality, affordable health care. Second, we must eliminate the waste that plagues our medical system — layers of bureaucracy that serve no purpose, duplicative tests and procedures that are performed because the right information is not readily available, and doctors providing unnecessary care for fear of being sued. Third, we need a public health infrastructure that works with our medical system to prevent disease and improve health.

We can work together to achieve guaranteed access to medical care during my first term in office. I talk to hardworking Americans every day who worry about paying their medical bills and getting and keeping health insurance for their families. In addition to this daily injustice, it is just plain costly and inefficient to care for people only when they get very ill. I have been committed to correcting this problem since I first started in public life, and I am determined to see it through.

Under my plan, if patients like the insurance they have, they keep it and nothing changes, except the costs are lowered. For those who are left out or have substandard insurance, my plan will offer a choice of affordable health insurance plans. Through a national health-insurance exchange, people without employment-based insurance or who work in small businesses will have a choice of private insurance policies at rates similar to those offered through large firms. To promote competition among insurers, we will also give patients a new public-plan option, providing the same coverage that is offered to members of Congress and their families.

All insurance companies will have to take everyone, regardless of medical history. Like too many Americans, I watched my mother argue with insurance companies while she was in bed dying of cancer; that should not happen.

To make insurance affordable, we will give families income-related tax credits to expand access and streamline plan enrollment and transactions to reduce the administrative burden. I will also expand Medicaid and the State Children's Health Insurance Program immediately to cover all children who don't have private coverage. And I have specified how I will pay for it — by cutting out waste in the system and redirecting the Bush tax cuts for the wealthiest Americans to help middle-class families afford health insurance.

Unlike some, I do not believe that Americans have overly generous insurance, so I would not impose a new tax on employer-based health insurance, giving employers an incentive to drop coverage and send tens of millions of Americans into the individual insurance market, where insurers cherry-pick healthy enrollees, administrative costs are high, and coverage is less comprehensive and cost sharing is greater. Such a plan would be disastrous.

Health care reform will not succeed unless we create a health care delivery system of which we can be proud. Report after report has pointed out the flaws in the way our system is organized and financed. Clinicians face huge administrative burdens that add to the cost of care and rarely improve its quality. Our reimbursement structure rewards procedures and the use of technology but not time spent with patients or coordinating care. There is little incentive for young physicians to enter into primary care. And U.S. physicians practice with constant concern about malpractice lawsuits.

I am committed to making the fundamental changes necessary to modernize the system to streamline medical practice with the goal of improved patient outcomes. My plan calls for investing $10 billion per year over 5 years in health information technology. This commitment is not just financial: we will ensure that physicians have the technical support they need to implement new systems for patient records and billing. By reducing medical errors and unnecessary duplication of tests, this investment will lead to a long-term reduction in our health care system's overall cost.

We also need to change the way we reimburse for patient care. We should start paying adequately for care coordination, case management, and innovative care-delivery models, such as team-based care and electronic communication. Doctors should be paid fairly by private insurers and by Medicare. Payment reform should improve patient outcomes and should lower overall costs by removing incentives for unnecessary care and rewarding the right care, provided at the right time, for the right reasons. Unlike my opponent, I voted against the recent reduction in physician payments. We can't start health reform by penalizing doctors.

Our medical training institutions are the finest in the world, but we need to ensure that doctors have ready access to the best information on medical advances throughout their careers. The best source of information on the value of a drug or a new technology is not the company that produces and markets it, but rather a careful and independent evaluation of patient outcomes. I will develop an independent national institute to work with the medical community to evaluate and disseminate information on the comparative effectiveness of drugs, devices, treatments, and procedures.

I will invest in programs, including loan repayment, training grants, and improved provider reimbursement, to give young doctors incentives to enter primary care. I will also renew our commitment to investing in biomedical research, which suffered a major lapse under the Bush administration.

Finally, I will address medical malpractice with the central goal of preventing medical errors in the first place. Through substantial investment in information and decision-support technology and other patient-safety initiatives, we will reduce the types of medical errors and oversights that lead to lawsuits. And I am open to additional measures to curb malpractice suits and reduce the cost of malpractice insurance. We must make the practice of medicine rewarding again.

Prevention is also a central part of my reform plan. Health care providers can do only so much; patients, employers, and communities all have a role in helping us to start out healthy and maintain our health. Patients need to step up their efforts to stop smoking, start exercising, and eat right to maintain a healthy weight. Employers need to invest in healthy workplaces and help their employees maintain an active, healthy lifestyle.

Government has a role, too. I will make new funding available for community-based programs aimed at priority public health problems such as smoking and obesity. I will also reward school and workplace health-promotion and prevention initiatives that increase vaccination and exercise and make healthy foods available in cafeterias and vending machines. Finally, I will work with state and local governments to create a coherent, coordinated national public health strategy.

This election will have enormous consequences for health care in our country. As president, I will modernize our health care delivery system and ensure that all Americans have access to high-quality, affordable medical care. I believe that with help and collaboration, especially from those who work so hard to keep us healthy, we can make health care reform a reality.

Source InformationThis article (10.1056/NEJMp0807677) was published at www.nejm.org on September 24, 2008.